Lung Transplantation: The Journey Continues

Transcription

1 Lung Transplantation: The Journey Continues Kathy Iurlano, RN BSN CCTC Cardiothoracic Transplant Coordinator Children s Hospital of Pittsburgh of UPMC Definition of Journey Something suggesting travel or passage from one place to another Children s definition add one travels a long distance and often the traveling may be dangerous or difficult 1

2 History of Lung Transplantation 1940s/50s animal attempts demonstrated the procedure was technically feasible first human lung transplant Univ of Mississippi first successful long term lung transplant survivor Lung transplantation less than 30 years! Children s Hospital of Pittsburgh First heart tx 1982 cyclosporine First combined heart/lung tx 1985 First lung tx 1989 Experimental FK506 tacrolimus/prograf 1989 First combined lung/liver tx 2010 NUMBER OF CENTERS REPORTING PEDIATRIC LUNG TRANSPLANTS BY CENTER VOLUME Number of Centers transplants transplants 5-9 transplants 1-4 transplants Transplant Year ISHLT 2012 Analysis includes living donor transplants J Heart Lung Transplant Oct; 31(10): DONOR TYPE DISTRIBUTION BY YEAR OF TRANSPLANT FOR PEDIATRIC LUNG RECIPIENTS (Transplants: ) 140 Number of Transplants Living Deceased 0 ISHLT 2012 J Heart Lung Transplant Oct; 31(10): NOTE: This figure includes only the lung transplants that are reported to the ISHLT Transplant Registry. As such, the presented data may not mirror the changes in the number of lung transplants performed worldwide. Analysis includes living donor transplants 2

3 PEDIATRIC LUNG TRANSPLANTS: Indications (Transplants: January June 2011) AGE: < 1 AGE: 6-11 AGE: Diagnosis AGE: 1-5 Years Year Years Years Cystic Fibrosis 1 1.1% 6 5.0% % % Idiopathic Pulmonary Arterial Hypertension % % % % Re-Transplant: Obliterative Bronchiolitis 7 5.8% 9 2.8% % Congenital Heart Disease % 9 7.5% 4 1.3% % Idiopathic Pulmonary Fibrosis 9 9.9% % % % Obliterative Bronchiolitis (Not Re-TX) % % % Re-Transplant: Not OB 3 3.3% 4 3.3% 9 2.8% % Interstitial Pneumonitis 1 1.1% 2 1.7% 3 0.9% Pulmonary Vascular Disease 8 8.8% 7 5.8% 4 1.3% 1 0.1% Eisenmenger s Syndrome 1 1.1% 5 4.2% 5 1.6% 7 0.6% Pulmonary Fibrosis, Other 6 6.6% 8 6.7% % % Surfactant Protein B Deficiency % 3 2.5% COPD/Emphysema 4 4.4% 2 1.7% 3 0.9% 9 0.8% Bronchopulmonary Dysplasia 3 3.3% 3 2.5% 7 2.2% 2 0.2% Bronchiectasis 1 1.1% 6 1.9% % Other % 6 5.0% % % ISHLT 2012 J Heart Lung Transplant Oct; 31(10): Analysis includes living donor transplants Referral/Evaluation Patient information Weekly conference Financial coverage out-pt evaluation Consultations: Pulmonology Cardiology CT Surgery Infectious Disease Behavioral Medicine Social Services Nutrition Child Life Transplant Coordinator Lung Transplant is a treatment not a cure and it is not a panacea. - EP Trulock 3

4 Tests Tests Echo/ekg Pfts/cxr/6 minute walk CT VQ scan Ultrasound abdominal for CF only Lab Work CBC/diff/plts/PT/PTT/INR BMP LFTs Blood type Tissue Typing - HLA Serologies HIV, hepatitis ABC, CMV,EBV,Toxo, HSV,Varicella HLA Tissue Typing Human Leukocyte Antigens HLA Candidate typing and antibodies Protein Reactive Antibodies PRA Pt serum tested again lymphocytes 100 donors Percentage reaction Luminex most sensitive AVOID strong/upper moderate antibodies HLA Tissue Typing Sensitization relevant to HLA Exposure to HLA antigens different from those HLA antigens of the recipient Exposure yields antibody formation targeted against the mismatched antigens Causes Prior transplants- exposure to other HLA antigens (non-self) via the new tx organ Blood or platelet transfusions Multiparous females 4

5 Antibody Types: Date Donor Specific Antigen Pre Post Class Type Antibodies 06/14/2012 No Pre Class II Moderate DR7 upper Edit mod 06/14/2012 No Pre Class II Weak DR9 Edit Conference discussion Evaluation discussed by multidisciplinary team Contraindications: absolute and relative If selected: Obtain insurance authorization > list Follow up in clinic Q 6 mo or more often 5

6 UNOS United Network for Organ Sharing Manages transplant waiting list 24/7 Maintains data base on all tx organs Members develop policies to make the best use of the limited organ supply Monitors every organ match to ensure allocation policies are followed Provide assistance to patients/families UNOS United Network for Organ Sharing Educates professionals Educates the public about organ donation Links Organ Procurement Organizations (OPO) and transplant centers Centralized computer network UNET Lung Allocation System Under 12 years Priority 1 criteria- Respiratory Failure Requiring continuous mechanical ventilation Requiring supplemental oxygen delivered by any means to achieve FiO 2 greater than 50% in order to maintain oxygen saturation levels greater than 90% Having an arterial or capillary PCO 2 greater than 50mmHg, or a venous PCO 2 greater than 56 mmhg Priority 2 criteria candidates who do not meet criteria 1 6

7 Lung Allocation System 12 years and older Lung Allocation Score LAS Functional status Diabetes Assisted ventilation Oxygen PFTs Heart cath data PA systolic pressure, mpap, PCW Blood gas Labs (H/H, creatinine) 6 minute walk results Donor Selection Blood group- ABO identical/compatible Age/height/weight Lungs ABO/height 10/25% Cause of death/downtime PMH no smoking/etoh or drug abuse Inotropes length Labs serologies/hla Vitals/CVP Lung function ABG PO2 > 400, vent settings Cxr, bronchoscopy, gram stain Location - <2 hours travel time 7

8 Who gets what??? No one is 1 st,2 nd or 3 rd on the LIST Dependent upon location of donor, height and ABO Donor: Donor Information Recipient: Blood group A Incompatable ABO Height 132 cm Too large Phoeniz Arizona Too far Blood group O Height 108 cm CHP The Call Coordinator on-call 24/7 Obtain donor information Recipient information Tissue typing, plasmaphoresis, etc 3 to 4 hours travel time to hospital 8

9 RECIPIENT AGE DISTRIBUTION FOR PEDIATRIC LUNG RECIPIENTS PERCENTAGE (Transplants: January June 2011) 100% 90% 80% % of Transplants 70% 60% 50% 40% 30% 20% 10% 0% < (N=602) /2011 (N=1,168) ISHLT 2012 J Heart Lung Transplant Oct; 31(10): Analysis includes living donor transplants Transplant Procurement/Surgery Donor team communicates with CHP surgical team TIMING IS EVERYTHING!! Transplant Surgery Approach: Bilateral transverse thoracosternotomy or clamshell Provides superior exposure and minimizes morbidity associated with transverse sternotomy Procedure: After initial dissection of hilar vessels, CPB is initiated Pneumonectomy is started after collasping the lung, blood vessels tied off, bronchi cut Topical cooling of allograft is critical- wrapped in gauze in ice bath new lung is placed, bronchial anastomosis performed first then vasculature Chest drains are placed, bronchoscopy is performed to assess mucosa and aspirate any blood/secretions from airways 4-6 hours operative time 9

10 clamshell approach Post-operative management CICU monitoring 5-7 days ekg blood gases systemic and pulmonary arterial pressures Pain control presidex, fentyl >intubated MSO4 > initially after extubation percocet> when taking PO Post operative management Ventilation Extubate ASAP Usually within 24 hours Lateral position first 12 hours Optimal oxygenation is achieved by: Minimizing fluid administration Careful use of diuretics and PEEP Aggressive utilization of chest PT 10

11 Post operative management Ventilation Ischemic/perfusion injury Sustained during perservation Hypoxemia, pulmonary HTN, pulm edema, diffuse opacification on cxr Treatment: nitric oxide Gas trapping - emphysema Phrenic nerve injury- rare complication Post operative management Hemodynamics Graft is sensitive to volume minimize fluid administration/careful use of diuretics Avoid hypotension causes: Vascular anastomotic complications - arterial stenosis/venous thrombosis requires surgical intervention heart failure MI or pulmonary embolism sepsis donor derived bacteria 11

12 Post Operative management Bronchoscopy detect rejection 2 weeks and 6 weeks post op Pleural drainage Removed when no air leaks/minimal drainage Nutrition Maximize, maximize, maximize Immunosuppression Thymoglobulin- T cell antibody depletes T cells induction therapy IV for first 5 days post op Follow B and T cell subsets Fever/chills premedicate PTLD post transplant lymphoproliferative disease Prograf (tacrolimus) Calcineurin inhibitor inhibits the effectiveness of T cells Start post op day 3-5 Capsules/suspension Monitor levels target Renal dysfunction, hypertension mycins, antifungals, antacids 12

13 Immunosuppression Cellcept (mycophenolate mofitil)- Anti-proliferative interferes with production of lymphocytes Start when tolerating PO Tablet/capsule/enteric coated GI symptoms- abd discomfort, diahrrea Steroids Rapamune (rapamycin)- mtor inhibitor Used in conjunction with calcineurin inhibitor Capsules/suspension Mouth ulcers other medications Hypertensive agents Insulin Gastrointestinal agents Prevacid, Prilosec, Zantac, Supplements Magnesium Calcium/vitamin D Antifungal agents Nystatin Voriconazole Antiviral agents Valganciclovir Donor/recipient serologies Follow EBV PCR/CMV PCR Rejection More susceptible than other tx organs Largest tx organ Extensive vasculature exposed to entire cardiac output Routinely exposed to the environment Contains large populations of immunologically active cells (macrophages,dendritic cells and lymphocytes 13

14 Rejection Surveillance biopsies 2,6,12 weeks post op Q 3 months first year 18 and 24 months Symptoms SOB Low grade temperature Lethargy Cough 10% decrease in pfts Rejection perivascular mononuclear cell infiltrates Grades 0-4 or X Classifications A acute rejection B inflamation C chronic rejection Chronic rejection=obliterative bronchiolitis (clinically - progressive airflow obstruction) 14

15 Infection Bacterial ATB plan Cover donor positive donor cx Viral EBV epstein barr ( mono) CMV cytomegloviris Fungal Vfend watch with Viral Infections EBV Donor status/primary infection PTLD post transplant lymphoproliferative disease Enlarged lymph nodes Rituxan therapy EBV PCR CMV Donor status/primary infection GI symptoms Diarhhea, abd discomfort ganciclovir IV/valcyte PO CMV PCR Patient Education Medications Signs/symptoms of rejection Follow up care VERY IMPORTANT TO IMPROVED OUTCOMES 15

16 Discharge/Follow up care Labwork Monitor CBC, lytes, lfts and theraputic drug levels Clinic visits Local pulm and transplant center PCP visits Routine well child care/sick care Surveillance biopsies Pathology to see old lungs Quality of Life School Activities Friends/family Donor communication 16

17 100% PEDIATRIC LUNG RECIPIENTS Cross-Sectional Analysis Functional Status of Surviving Recipients (Follow-ups: April 1994 June 2011) 80% 60% 40% 20% No Activity Limitations Performs with Assistance Total Assistance 0% 1 Year (N = 330) 3 Years (N = 206) 5 Years (N = 128) ISHLT 2012 J Heart Lung Transplant Oct; 31(10):

18 THE BAD NEWS. Survival (%) PEDIATRIC LUNG TRANSPLANTS Kaplan-Meier Survival by Era (Transplants: January June 2010) (N=216) (N=511) /2010 (N=828) HALF-LIFE (Years) Unconditional : 2.5; : 4.0; /2010: 5.8 Conditional : 10.4; : 7.3; /2010: vs : p = vs /2010: p < vs /2010: p = N at risk = 27 N at risk = 10 N at risk = Years ISHLT 2012 J Heart Lung Transplant Oct; 31(10):

19 Causes of late deaths Chronic rejection Infection Respiratory failure CMV Malignancy Non-compliance Conclusions Lung transplant is not a cure it is an exchange of one disease process for another Quality of life improvement 50% patient survival at 5 years per ISHLT data 19